Healthcare Provider Details

I. General information

NPI: 1306689682
Provider Name (Legal Business Name): MOLDING HEARTS ORG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 PRESCOTT AVE
YUCCA VALLEY CA
92284-5914
US

IV. Provider business mailing address

6805 PRESCOTT AVE
YUCCA VALLEY CA
92284-5914
US

V. Phone/Fax

Practice location:
  • Phone: 951-464-8587
  • Fax:
Mailing address:
  • Phone: 951-464-8587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. LAKITA T JOHNSON
Title or Position: CEO
Credential:
Phone: 951-464-8587